Maryland CC Project Smith – Management of Refractory Distributive Shock
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Aug 18, 2024 Dr. Lane Smith, a critical care medicine specialist at Atrium Health Carolinas Medical Center, dives deep into refractory distributive shock treatment. He discusses the innovative use of angiotensin II, shedding light on its methodology and outcomes. The conversation navigates the challenges of managing critical care in ICU settings, particularly focusing on organ dysfunction and treatment customization. Smith emphasizes the evolution of vasopressors, advocating for critical thinking in clinical practice as new alternatives emerge.
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Organ Dysfunction Drives Mortality
- Mortality in distributive (mostly septic) shock is driven by number and severity of organ dysfunctions rather than the infecting organism alone.
- Changing a monitor number like blood pressure is not equivalent to reducing mortality or organ support needs.
Norepinephrine As First-Line Default
- Norepinephrine is established as the default first-line vasopressor for distributive shock over dopamine and others.
- Choice among vasopressors rarely changes mortality; norepinephrine is usually a safe starting option.
Confirm Shock Etiology Before Escalation
- Before escalating vasopressors, confirm the shock type and look for hypovolemia, tamponade, RV failure, or hemorrhage that need other therapies.
- Reassess early rather than just increasing catecholamines when pressor needs escalate rapidly.